Saturday, February 27, 2010

Last week I was invited to join Associate Professor Lisa Hanson and her two midwifery students Milwaukee, USA, as they had a class in the virtual birthing unit. This was a significant event for the virtual birthing unit because it was the first time it had been used for a 'formal' teaching session, as opposed to being part of a evaluation project. It was also the first time (to my knowledge) that it was used by midwifery educators and students outside New Zealand.Some thoughts about teaching in the Second Life birthing unitThis was the first time I was able to observe the scenario being played out without taking an active part as the 'teacher'. A few things struck me during our two hour session.

Things work so much better if the teacher and students have had a little experience in Second Life before they start to work in the birth unit. The scenario is very complex and will be extremely off-putting to people who have had no experience of Second Life. Lisa and her students had done some preparatory work, and it made things run a lot smoother.

Each scene takes about two hours, which includes getting orientated to the scenario, working through the scene and debriefing afterwards.

The two people working through the scene can be supported, 'coached' and prompted by private instant message - the coaching can also be done in local chat so everyone sees the comments and questions that are being asked.

The debrief session after each scene was really valuable because Lisa was able to ask the students questions and give them supporting information which enhanced what happened during the scene. This was especially interesting for me to observe. I had designed the scenario so that students could work there without a lecturer. However, I felt that valuable learning went on with Lisa, who is an experienced educator and midwife, who was able to coach and stretch the students to go one step further in their thinking, both in the scene and in the debrief. I was thinking that matching senior students with junior students might work really well - that the senior student is the coach in place of the lecturer. This would give the senior student the opportunity to develop 'teaching' skills and provide ongoing support for the junior students.

The first scene that enables students to work through a phone call from a woman in early labour is really valuable. Students do not often get the opportunity to assess women on the phone, so this scene gives them an authentic learning opportunity. That first phone call can set the scene for a woman's labour and birth, so it is important that midwifery students know how to assess a woman's progress by telephone, and make decisions accordingly.

The scenes need to be developed and further variables added to give the scenario more depth and complexity - this will make the scenario even more re-usable and prevent students getting bored with seeing the same information time and time again.

Personal thoughtsI am thrilled to say the least that the birth unit is being used by midwifery educators. I would have been gutted it became an empty virtual relic after all the time, effort and money that went into its development.

I had heaps of fun working with Lisa and the students, and felt very privileged to be included in their lesson. I also marvel at the wonders of modern technology that allowed me to sit in my kitchen in Dunedin, New Zealand and be part of the learning experience of students based in the USA. To me, this international collaboration and cooperation is a very powerful learning opportunity for the midwifery profession.

Future collaboration and researchLisa and I are looking to develop a research proposal so that we can look at learning outcomes when Lisa uses the birth unit later this year with a bigger class of students. What I want to know is exactly how it helps students and what effect, if any, it has on grades, levels of knowledge and understanding, and clinical competence and confidence.

There is a need to obtain funding to further develop the scenario without taking outside the realms of normal birth. This is something I feel I need to look at fairly urgently this year.

Tuesday, February 23, 2010

I have just had this email from a new student midwife in Australia, who is also a registered nurse, who wants to know how we know what we know:

"[is]...professional decision making based on knowledge gained from research, experience, theory or is it simply described as gut feeling or intuition" Taking into account your background as registered nurses write a REPORT on 'How do you know what you know"

... being so novice I am having trouble getting my head around this question. I can argue both sides as common sense prevails however for best practise in midwifery it is important to always be up to date with best practice methods and procedures. I am wondering if you are able to continue a discussion with me..."

As an experienced midwife and educator, I would say that my midwifery knowledge is made up of a number of elements - evidence of research, consensus of what is best practice at a professional level, what I have been 'told' by experienced colleagues and wise women, evidence from my own experience, understanding that has come from personal reflection, knowledge from the women and families I work with.

I also believe midwives 'know' from intuition although I do not fully understand what intuition is. Is it a lightning 'feeling' that comes to you with no rhyme or reason...as if by magic? Or does it come about as a result of experience...a subconscious knowledge or understanding that we do not even know we have?

If you are a midwife, how do you know what you know?

If you are not a midwife, what do you understand about intuition? Have you ever had a situation where your intuition has kicked in and impacted on your actions?

Monday, February 22, 2010

I am just finishing off my preparation for my Midwifery Standards Review in March, and just wanted to quickly reflect of the feedback I have received from colleagues, which is a requirement for Standard Eight.

On the whole, I think I am quite hard on myself when I am reviewing my practice. So I find it is really useful to receive collegial feedback because that often puts things into perspective. It appears that I am meeting the challenges of communication in the context of locum midwife.

"...women who received antenatal and postnatal care from Sarah during those times was very positive, they all noted how easily she developed a rapport with them, despite being so busy and in such a vast and unfamiliar remote area. Many commented on how friendly and easy to talk to she was, and that the information she shared with them was done so in manner which they clearly understood. 2 of these women spoke little English and had recently arrived here from a country with a very different maternity system."

It has also been great to receive validation of my midwifery practice, especially as I have not worked in the clinical context for a while.

"I was so very pleased to have her support. She was calm and confident during a labour and birth (apparently her first in a rural location for some time). I know the woman and her partner were very appreciative of Sarah’s presence, and extremely grateful that Sarah identified when their son began to show signs of a GBS infection, and promptly arranged and accompanied them to the NNU at Base hospital."

A big 'thank you' to the Lumsden midwives who put up with me last year :)

Saturday, February 20, 2010

This year has been a little experiment to see what vegetables I can grow in my very small garden, and what I can manage to grow in pots and bags.

FailuresI have discovered I cannot grow rhubarb for love nor money, and my spinach got eaten before it came to anything. I have three tubs of strawberries that have produced no more than half a dozen very small fruit. And my tomatoes, both in the garden and in tubs, have grown into huge bushes with lots of flowers, but no sign of any fruit - I am hoping that we have a sunny Autumn to encourage them to come on.

SuccessesI have one pot growing a courgette plant and that is doing really well with lots of fruit- I would need to grow another two or three pots to get a decent number of courgettes, which I will do next year. My potatoes in bags are shooting up all over the place, so I am hoping for a good yield from them.

My major success has been the broccoli that I have planted into between flower plants - they have taken over what little garden I have, and it looks like I will get a crop that will keep my husband and I going for quite a few weeks.

It has been an expensive exercise growing vegetables in pots, by the time I bought soil, compost, pots and so on. No doubt it would have been much cheaper to go to the farmers' market every Saturday and get my vegetable supplies there. However, it has been great fun watching the plants grow, and I am a bit like Prince Charles......I go out and talk to the plants every evening and tell them how beautiful they are...to try to encourage them to grow more....my kids think I am turning into a dotty old woman!

What do you find grows well in pots, and what should be kept in the garden?

Tuesday, February 16, 2010

I have been rushing home from work to catch the last couple of hours of the 2010 Winter Olympics. Over the last couple of days I have been glued to the pairs figure skating, which has taken me back to happier days of British skating - and you just cannot beat the the wonderful ice dancing of Torvill and Dean.

One of the biggest challenges for midwives (or any health professional) is documentation. It is vital we thoroughly document all our assessments, actions, and discussions we have with the women we care for. Documentation provides a record for other health professionals, evidence of our care, and it tells a story for women and their families.

The framework I use loosely for clinical documentation is called SOAP:

Subjective - what the woman feels

Objective - the woman's symptoms

Assessment

Plan

The tension of midwifery documentationIn New Zealand, pregnant women carry their own notes so midwives are not only documenting for professional reasons but they are telling the story of the woman's pregnancy and birth, for the woman and her family. In my experience, this has created a tension in terms of writing style and time. Somehow you have to get a balance between writing in a concise way that makes sense to any health professional you may be referring to. You have to be thorough and detailed so your notes stand up in a court of law in years to come. At the same time, you must write in a way that the woman and her family can understand, which all takes time.

Thinking about my documentationOver the years I have struggled to write my clinical notes in a family-centred way. I was taught to be short, concise and clinical, and I still follow the format I was taught as a student midwife over 20 years ago - this is to make sure I do not forget anything.

But I found that when I was a Lead Maternity Carer and became part of a woman's life for nearly a year that it was so much easier to take the 'story-telling' approach to writing women's notes - if for no other reason than I had become part of that story.

Writing notes as a locum midwifeMy complacency about documentation was challenged last year during my stint as a locum midwife. One woman felt that I didn't write enough details - I didn't do any story-telling, especially when compared to her LMC. This highlighted the difficulty of 'story-telling' when you are making only one or two visits to the woman and family, compared to nine or more months of intimate relationship as primary care-giver.

Future practice I have become a lot more conscious of what and how I write as a locum midwife. And if nothing else, this feedback has yet again empathized how important details are in documentation, especially when you flit in and out of a woman's life on a temporary basis.

If you are a health professional, what framework do you use for clinical documentation? If you are a health consumer, pregnant mum or patient - especially if you have access to your clinical notes - how do you like to see them written? What do you like to see your health professional write about you?

In the good old days, you heard about the birth of a baby in the newspaper. These days, you are much more likely to hear about it via Twitter, Facebook or Youtube.

My dear friends Leigh and Sunshine have just had a little girl called Eve and I am delighted to be able to hear all about her on various social media channels. Sadly, the family is in Canberra so I cannot see them face-to-face at the moment. But I still feel very connected to what they are up to.

Saturday, February 13, 2010

Midwives in New Zealand are expected to give feedback forms to all the women they care for. The forms are returned to the midwife so she can reflect on the care she has given women. This reflection becomes part of the midwife's Review process - the midwife is also expected to submit the forms to the Review Committee so the committee can comment.

My feedback for 2006 I received five feedback forms in 2006. Most of the feedback was excellent. My favorite was this comment:

"Brilliant. 2nd time with this midwife who I trust immensely"

However, one woman did have a few problems with the way I communicated with her. Whilst she felt my care when she was in labour was good, she felt I didn't always listen to or understand her, nor did I adequately individualize her care.

How to respond to feedbackReceiving feedback as a midwife can be difficult at times because it is so personal. On the whole I do a very good job but every now and again, things do not go as well as I would like. Sometimes it is difficult to tease out what feedback one should act on, and what is a personality clash. So what I look for in feedback is themes - if a comment keeps cropping up, then I know this is something I must respond to.

When a woman says I have not communicated appropriately, this is something I must pay attention to. I do not believe this is a theme in my practice and my feedback reflects this. However, appropriate communication is a key element of midwifery practice so it is important I remain vigilant to ensure my standards do not drop.

If you are a health professional, how do you gather feedback from the people you care for? As a health consumer, how do you give feedback to your doctor/nurse/midwife?

Life-long learning does away with expertsThe discussion that arose was very interesting. There appeared to be agreement amongst the participants that the concept of life-long learning has done away with the teacher as an expert - the argument being that we cannot be 'experts' as we are always learning.

Why can't educators be experts?To be honest I am a tad unsettled by this argument. Yes, I totally agree that educators should not take the "I am an expert so you should do what I say" approach to teaching. And yes, I think we should facilitate learning. However, when I was a midwifery educator I considered myself to be an expert in some areas. I was always learning from students and I never claimed to know all there is about a subject. I used students' own expertise and knowledge. But none the less, there were times when I felt it was appropriate to take a "this is what you do" approach to presenting a topic or subject especially when teaching clinical skills.

Experts or expertise?It was a conversation on Twitter that has helped me figure this out in a more satisfactory way. I asked what people thought about experts and teaching - and it was Andrew Hazlet who replied

I prefer "expertise" to "experts" - most knowledge isn't static or permanent

My teaching philosophy So I am thinking that I am a facilitator of learning with an expertise in such and such subject or skill. And it has dawned on me that my teaching philosophy is similar to my midwifery philosopy - I walk around the learning (or childbirth) road with my student or client. Sometimes we walk together - sometimes I lead, and other times the student or woman leads. Sometimes we get to our destination together, other times we end up in completely different places.

Here are the slides I used on Saturday which were designed to facilitate discussion as opposed to 'teach'.

Monday, February 8, 2010

I attended an online presentation at the weekend by Helen Barrett, who is the doyenne of ePortfolios. She is coming to the realisation that ePortfolios should be utilising online tools that students are already using like YouTube, FaceBook, Twitter etc.

Helen advocates a similar approach to what I am taking with my ePortfolio - using social media tools to generate and collect data, and present everything in an online platform that is a personal choice like Google Docs or Google Sites.

I am wondering if I would be better off using Google sites for my midwifery Review ePortfolio so I can keep it closed to everyone but the Review Committee.

Knowing a little of the history of those times this doesn't come as any surprise to me. It also makes me wonder how much of the knowledge we take so much for granted today has come by similar murderous means?

Taking into account the context that these men worked in and the fact that their research has saved many women since, does this news change your view of them and make them any less remarkable?

Sunday, February 7, 2010

How do I attract the people that I want to communicate with – even those who are presently unknown to me? I know that I have followers but how do I tweet to them?

Here are a few suggestions from my own experience of using Twitter.

1. Send regular messages, otherwise known as 'tweets'You can't expect people to talk to you if you do not talk to them. It's like being at a party - if you want to be part of the fun, you have to go up to people and start a conversation. You don't want to overwhelm people with hundreds of tweets every day, but I would suggest you aim for at least a couple of tweets per day. I am less likely to follow someone if I see they interact infrequently.2. Be friendly and openAlways reply to people when they send you a message, especially when you are building up your network.

3. Don't be shyBe prepared to introduce yourself to people and explain who you are, why you are following them and start up a conversation. Some people will not respond, so don't be put off by that.

4. Think about carefully about your Twitter nameWhatever name you use, make sure it fits with your 'brand'...in other words how you want to be known online. If you want to build a professional network, it's probably not a good idea to call yourself "sexykittonkisses" or similar. Think about how you hook people into your Twitter stream when they first hear from you - if you use a really obscure name, you may put people off following you because they don't understand who you are.

5. Make sure your profile explains who you areThis is especially important if you wish to develop a professional network. People need to know why they should follow you. They will also want to make sure you are a legitimate person, not a spammer or marketing company.

6. Follow people who have an established following on TwitterBy doing this, you will get more of a sense of how to develop a network and see who are useful and interesting people to interact with.

Having said that, be mindful that some people have huge numbers of followers because of who they are as opposed to what they say on Twitter. For example, I used to follow Willam Shatner who has over 150,000 followers because I wanted to keep up with what he was doing and thinking (I just LOVE him!). But I stopped following him when I realized he doesn't send out tweets very often - I didn't feel connected to him.... (I'll just have to figure out another way to stalk him!!)

7. Share information and messages that will be of interest to peoplePost about websites, resources and events. Re-tweet (pass on) messages you have seen that may be of interest to your followers.

8. Be helpfulIf I have time and am able to help, I always respond to calls for advice and support. I find that what goes round, comes round on Twitter - in other words, if I help people, they are willing to help me.

9. Tailor your message to your networkIf you are trying to build a network, have a think about who you want to attract. It's no good expecting to engage with educators if all you do is tweet about gardening.

10. Use key wordsPeople search and follow themes and key words. So if you want followers who have an interest in gardening, use 'gardening' words in your messages that can be found in search engines. I happened to mention once that I was learning how to play Poker, and within minutes was being followed by people who obviously had an interest in Poker.

11. Don't be afraid to add personal touches to your messagesYou don't want to bore everyone with details of your mundane life. At the same time, I think it is useful to tweet about your personal life at times - it gives your followers the chance to get to know you better and connect with you on another level.

12. Be prepared to put in time and effort to build your network and communityI am a firm believer that you get out of Twitter what you put in.

ResourcesIf you are interested in knowing more, have a look at these resources:

Building your Twitter network - I really like the advice in this article to put your blog/website address in your Twitter profile which gives people more information about who you are and what you are interested in

Thursday, February 4, 2010

One of the things I have to do for my Midwifery Standards Review in March is reflect on my midwifery case statistics. So I have been thinking about how I can present my statistics in an open way so anyone who is interested can have a look, yet protect the identity of the women involved. The conclusion I have come to is to talk about my stats in general terms in an open environment without becoming specific. This is especially important for me because I had such a small caseload, making it a lot easier to identify individual women.

Electronic statisticsIn terms of my ePortfolio, my stats are sent to me from the MMPO (the practice management service I belong to) as an electronic file so all I have to do is keep it 'as is' on my hard drive, or upload it onto a password protected website. I can give access to those who need to see the raw data, such as my Reviewers.

Comparison with national statisticsThe other interesting thing that came through with my stats is a summary of what midwives who are registered with the MMPO are doing on a national level, so I can compare my stats with national trends.

Lies, lies and damn statisticsI had such a small caseload that it is impossible to make comments about statistical trends - but it's still interesting to have a look. In the year 2006, I attended 7 births:

I was Lead Maternity Carer (LMC) for 5 of the women for their whole pregnancy, birth and 6 weeks after the birth

2 women I was LMC for just the labour and birth

2 birth were home births

2 births resulted in emergency cesarean section

3 were vaginal births in hospital.

This comparison is with national statistics released by MMPO from March 2008 to February 2009 - 24,447 labours and 24,715 babies.

If you are interested in looking at more New Zealand maternity statistics, have a look at the latest Report on Maternity 2004.

What do my stats tell meIn general it looks like my intervention rates are higher than the national average. This is explained by the fact that two women ended up having emergency cesarean sections and one woman had an emergency induction of labour because she had fulminating pre-eclampsia. These higher intervention rates are nicely balanced by the fact that I had two home births and 100% exclusive breastfeeding at discharge.

Reflecting on my statisticsMy main concern has been my epidural rate - four of the five women who birthed in hospital had an epidural for pain relief, and of those four women, two of them had cesarean sections. I have been left with several questions:

Does Epidural for pain relief increase women's chances of having an cesarean section?

What can I do to support women in labour so they do not feel they have to resort to epidurals?

What influences women's decision to have an epidural that I have no control over, and does that reflect on my abilities as a midwife?

Epidural and Cesarean SectionsThe latest Cochrane Review shows no association between epidural and cesarean section but there is a increase in instrumental vaginal births such as forceps. However, this has been disputed by other doctors and researchers who have found that epidurals cause a rise in Cesarean Section. My own feeling is that there is a connection, along with induction and augmentation of labour. It is also my observation that careful management of an epidural in the second stage of labour increases vaginal birth if you let nature take its course, even if it increases the length of second stage.

What am I doing wrong?Looking at this high rate of epidural, I have been asking myself what I am doing wrong as a midwife? Am I providing adequate support to women? What alternative forms of pain relief should I be offering? Do I "cave in" too early to women's requests for epidural? Should I take the stance that some midwives do - refuse to care for women who want an epidural.

I always consider an epidural to be the last resort. I talk to women before they go into labour about epidurals and try to do the best I can to talk them out of having one. I tell them that they have to ask for one - I will not offer it to them. I try not to take the 'menu' approach to pain relief that Nicky Leap talks about - that I work with women to work with their pain. I am also a great believer in the power of water in labour.

Influence of place of birthBut I am mindful that the place of birth influences both the woman's and midwife's decisions about pain. And because I work in a tertiary maternity unit, I do think that over the years my skills of supporting women in normal birth have been eroded. It is so much easier to arrange an epidural when the anesthetist is practically camped outside the door, and I believe that has impacted on my practice.

The decision I have come to is that I no longer want to practice midwifery in a tertiary maternity center because I feel I cannot fully function as a midwife in that environment. And as that is my only choice in Dunedin (apart from home births), I have decided that from now on I will only work in primary units, which means working in rural units in Otago and Southland. This way I will work with women who are committed to normal birth, and I will work to my full midwifery scope of practice.

I would love to hear your views. If you are a midwife, what do your statistics tell you about your midwifery practice? If you are a health consumer, do you ever think about a midwife or doctor's practice statistics? Would they influence how you feel about that health practitioner?

Monday, February 1, 2010

Sarah Stewart

Welcome to my blog which is a mix of talk about stuff that takes my fancy. My views are my own and not necessarily of my employer, the Australian College of Midwives. I am always really interested to hear your thoughts and feedback, so please feel free to leave a comment at any time.